Multidisciplinary practical guidelines for gastrointestinal access for enteral nutrition and decompression from the Society of Interventional Radiology and American Gastroenterological Association (AGA) Institute, with endorsement by Canadian Interventional Radiological Association (CIRA) and Cardiovascular and Interventional Radiological Society of Europe (CIRSE).

Background: Excluding pulmonary embolism, anastomotic leak is the leading cause of death and major morbidity in patients undergoing open or laparoscopic gastric bypass operations. We observed a number of these leaks (11 out of 1,120 MicropouchSM gastric bypass [MGB] patients; 0.9%). The majority (80%) required emergency laparotomy and drainage, massive fluid resuscitation, and aggressive nutritional support. Therefore, we designed a 2-year, prospective study to determine the therapeutic efficacy of vapor-heated fibrin sealant to prevent anastomotic leaks at the gastro-jejunostomy (GJS) site. Methods: Between April, 2000 and March, 2002, 738 patients underwent a primary (n=671) or revisionary (n=67) MGB procedure.The gastric reservoir was limited to the cardia of the stomach. Vapor-heated fibrin glue 1 cc was applied circumferentially to a 12-mm, non-banded GJS anastomosis. Once activated, fibrin sealant polymerized into a soft, closely adherent gel. No omental patch was used to cover the fibrin-sealed anastomosis. Results: Of 738 patients, 2 required emergency laparotomy for leaks and 2 for adhesive bands that contributed to a distal small bowel obstruction.There were no anastomotic leaks at the fibrin-sealed GJS sites. No gastro-gastric or gastro-enteric fistulas were recorded. Conclusion. Fibrin sealant applied to the GJS site appears to have eliminated anastomotic leaks in our MicropouchSM gastric bypass patients. These results suggest that fibrin glue application may contribute to "leak prophylaxis" in patients undergoing open Rouxen-Y gastric bypass. Glue placements may also benefit patients undergoing a laparoscopic Roux-en-Y procedure, wherein anastomotic leaks have been reported early in the learning curve.

Anastomotic Leak Prophylaxis Using a Vapor-Heated Fibrin Sealant: Report on 738 Gastric Bypass Patients

OBJECTIVE. Retrospective analysis was performed to determine the safety and effectiveness of percutaneous gastrostomy for treating distention of the bypassed stomach after gastric bypass for morbid obesity.MATERIALS AND METHODS. Eight patients with morbid obesity and Roux-en-Y gastric bypass underwent percutaneous radiologic gastrostomy for postoperative decompression of the bypassed stomach. Four patients underwent gastrostomy on the fourth day after surgery: two in the early postoperative period (≤ 30 days after surgery) and two in the late postoperative period (6, 11 months after the procedure). Procedures were performed using combinations of fluoroscopic, CT, and sonographic guidance. T-tacks and a variety of locking pigtail drainage catheters were placed in seven patients.RESULTS. Gastrostomy placement was technically successful in all patients. Seven of eight patients experienced resolution of symptoms. Gastrostomy catheters were in place for a mean of 31 days. Two complications occurred. Periproced...

Percutaneous Gastrostomy for Treating Dilatation of the Bypassed Stomach After Bariatric Surgery for Morbid Obesity

Anastomotic leaks after Roux-en-Y gastric bypass (RYGB) potentially result in considerable morbidity and mortality. In the present report we describe our experience with the management of gastrojejunal anastomotic leaks. Tachycardia and fever are considered early signs of anastomotic disruption. Patients weighing less than 350 pounds underwent radiographic testing to diagnose gastrojejunal disruption. Those with severe leaks or patients too large for radiographic evaluation underwent exploratory laparotomy. For severe anastomotic disruptions a retrograde transanastomotic jejunal sump drain was placed. Twenty-four (1.3%) anastomotic leaks occurred in 1789 RYGBs. Five of the leaks were classified as severe and required retrograde sump tube placement. There was one mortality and all of the other patients completely recovered. Aggressive and early intervention for anastomotic disruption after RYGB is necessary to ensure the best possible outcomes for patients with this complication. A high index of suspicion for leaks in postoperative RYGB patients with tachycardia is required if patients are to have good outcomes when complications develop.

Management of gastrojejunal anastomotic leaks after Roux-en-Y gastric bypass.

Percutaneous Gastrostomy of the Excluded Gastric Segment after Roux-en-Y Gastric Bypass Surgery

Background: Since 1994 we have performed the "micropouch" gastric bypass (MGB) procedure for morbid obesity. In our MGB operation, the transected gastric reservoir is limited to the cardia of the stomach. The Roux and biliopancreatic limbs measure 200 and 150 cm, respectively; radiographic or endoscopic access to the bypassed stomach is therefore excluded. Methods: A retrospective analysis of 1,120 MGB operations revealed that 33 patients (2.9%) developed a potentially life-threatening postoperative complication requiring emergency re-operation or prolonged hospitalization. Complications included anastomotic leaks, fascial dehiscence, gastroenteric obstructions, peptic ulcers, and pancreatitis. Each complication was analyzed to determine if gastrostomy tube (G-tube) placement at the time of gastric bypass could have affected complication outcome or obviated the need for repeat laparotomy. Results: In 19 patients (1.6% of total cohort), G-tube placement would have significantly affected complication outcome. In four instances, it would have prevented emergency re-operation. Conclusions: Routine gastrostomy tube placement at the time of gastric bypass is not necessary in all patients. For patients who are at high risk for a gastro-enteric obstruction or an anastomotic leak, G-tube placement is recommended and is often therapeutic.

Micropouch Gastric Bypass: Indications for Gastrostomy Tube Placement in the Bypassed Stomach

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Micropouch Gastric Bypass: Indications for Gastrostomy Tube Placement in the Bypassed Stomach